9/10/2015

CancerStaging
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CancerStaging
Stagingistheprocessoffindingouthowmuchcancerisinapersonsbodyandwhereitslocated.Itshowthe
doctordeterminesthestageofapersonscancer.
Formosttypesofcancer,doctorsusestaginginformationtohelpplantreatmentandtopredictapersonsoutlook
(prognosis).Althougheachpersonssituationisdifferent,cancerswiththesamestagetendtohavesimilaroutlooks
andareoftentreatedthesameway.Thecancerstageisalsoawayfordoctorstodescribetheextentofthecancer
whentheytalkwitheachotheraboutapersonscancer.

Whyisstagingneeded?
Doctorsneedtoknowtheamountofcancerandwhereitisinthebodytobeabletochoosethebesttreatment
options.Forexample,thetreatmentforanearlystagecancermaybesurgeryorradiation,whileamoreadvanced
stagecancermayneedtobetreatedwithchemotherapy.Doctorsalsouseacancersstagetohelppredictthe
courseitwilllikelytake.
Inalargersense,doctorsusestaginginformationwhentheyrestudyingcancertreatments.Itallowsresearchersto
makesurestudygroupsareactuallysimilarwhentheytestcancertreatmentsagainstoneanother,measure

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outcomes,andmore.
Notallcancersarestaged.Forexample,leukemiasarecancersofthebloodcellsandthereforespreadthroughout
thebody.Mosttypesofleukemiasarentstagedthewaycancersthatformtumorsare.

Whatisthedoctorlookingforwhenstagingcancer?
Whentryingtodeterminetheextentofthecancerinthebody,doctorsfirstlookattheprimary(main)tumorforits
size,location,andwhetherithasgrownintonearbyareas.Doctorsalsocheckforothernearbytumors.
Doctorsmightalsolookatnearbylymphnodestofindoutifcancerhasspreadintothem.Lymphnodesaresmall,
beanshapedcollectionsofimmunecells.Manytypesofcanceroftenspreadtonearbylymphnodesbeforethey
reachotherpartsofthebody.
Doctorsmightalsolookatotherpartsofthebodytoseeifthecancerhasspreadthere.Whencancerspreadsto
partsofthebodyfarfromtheprimarytumor,itisknownasmetastasis.
Insomekindsofcancer,otherfactorsarealsousedtohelpdeterminethestage,suchasthecancercelltypeand
grade(howabnormalthecancercellslookunderamicroscope),ortheresultsofcertainbloodtests.

Howarecancersstaged?
Doctorsusedifferenttypesofexamsandteststofigureoutacancersstage.Dependingonwherethecanceris
located,thephysicalexammaygivesomeclueastohowmuchcancerthereis.Imagingtestslikexrays,CTscans,
MRIs,ultrasound,andPETscansmayalsogiveinformationabouthowmuchandwherecancerisinthebody.
Abiopsyoftenisneededtoconfirmacancerdiagnosis.Biopsiesmightalsobeneededtofindoutifanabnormalspot
seenonanimagingtestisreallycancerspread.Duringabiopsy,thedoctorremovesatumororpiecesofatumorto
belookedatunderamicroscope.Somebiopsiesaredoneduringsurgery.Butwithmanytypesofbiopsies,the
doctorremovessmallpiecesoftumorthroughathinneedleorthroughaflexiblelightedtubecalledanendoscope.
ThedifferentkindsofbiopsiesusedtocheckforcanceraredescribedinAGuidetoCancerSurgery.

Typesofstaging
Stagingisdonewhenapersonisfirstdiagnosed,beforeanytreatmentisgiven.Themaintypesofstagingare:

Clinicalstaging
Thisisanestimateoftheextentofthecancerbasedonresultsofphysicalexams,imagingtests(xrays,CTscans,
etc.),andtumorbiopsies.Forsomecancers,theresultsofothertests,suchasbloodtests,arealsousedinstaging.
Theclinicalstageisakeypartofdecidingthebesttreatmenttouse.Itsalsothebaselineusedforcomparisonwhen
lookingathowthecancerrespondstotreatment.

Pathologicstaging
Ifsurgeryisbeingdone,doctorscanalsodeterminethepathologicstage(alsocalledthesurgicalstage)ofthe
cancer.Thepathologicstagereliesontheresultsoftheexamsandtestsmentionedbefore,aswellaswhatis
learnedaboutthecancerduringsurgery.Oftenthisissurgerytoremovethecancerandnearbylymphnodes,but
sometimessurgerymaybedonetojustlookathowmuchcancerisinthebodyandtakeouttissuesamples.
Sometimes,thepathologicstageisdifferentfromtheclinicalstage(forinstance,ifthesurgeryshowsthecancerhas
spreadmorethanwasthought).Thepathologicstagegivesthehealthcareteammorepreciseinformationthatcanbe
usedtopredicttreatmentresponseandoutcomes(prognosis).

Stagingsystems
Therearedifferenttypesofstagingsystems,butthemostcommonandusefulstagingsystemformosttypesof
cancersistheTNMsystem.

TheTNMsystem
TheAmericanJointCommitteeonCancer(AJCC)andtheInternationalUnionforCancerControl(UICC)maintainthe

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TNMclassificationsystemasatoolfordoctorstostagedifferenttypesofcancerbasedoncertainstandards.Its
updatedevery6to8yearstoincludeadvancesinourunderstandingofcancer.
IntheTNMsystem,eachcancerisassignedaletterornumbertodescribethetumor,node,andmetastases.
Tstandsfortheoriginal(primary)tumor.
Nstandsfornodes.Ittellswhetherthecancerhasspreadtothenearbylymphnodes
Mstandsformetastasis.Ittellswhetherthecancerhasspreadtodistantpartsofthebody
TheTcategorygivesinformationaboutaspectsoftheoriginal(primary)tumor,suchasitssize,howdeeplyithas
grownintotheorganitstartedin,andwhetherithasgrownintonearbytissues.
TXmeansthetumorcantbemeasured.
T0meansthereisnoevidenceofaprimarytumor(itcannotbefound).
Tismeansthatthecancercellsareonlygrowinginthemostsuperficiallayeroftissue,withoutgrowingintodeeper
tissues.Thismayalsobecalledinsitucancerorprecancer.
NumbersaftertheT(suchasT1,T2,T3,andT4)mightdescribethetumorsizeand/oramountofspreadinto
nearbystructures.ThehighertheTnumber,thelargerthetumorand/orthemoreithasgrownintonearbytissues.
TheNcategorydescribeswhetherthecancerhasspreadintonearbylymphnodes.
NXmeansthenearbylymphnodescannotbeevaluated.
N0meansnearbylymphnodesdonotcontaincancer.
NumbersaftertheN(suchasN1,N2,andN3)mightdescribethesize,location,and/orthenumberofnearby
lymphnodesaffectedbycancer.ThehighertheNnumber,thegreaterthecancerspreadtonearbylymphnodes.
TheMcategorytellswhetherthecancerhasspread(metastasized)todistantpartsofbody).
M0meansthatnodistantcancerspreadwasfound.
M1meansthatthecancerhasspreadtodistantorgansortissues(distantmetastaseswerefound).
Mostcancertypeshavetheirownversionofthisclassificationsystem,solettersandnumbersdontalwaysmean
thesamethingforeverykindofcancer.Forexample,insometypesofcancer,theTcategoriesdescribethesizeof
themaintumor,whileinotherstheydescribehowdeeplythetumorhasgrownintotheorganitstartedin,orwhether
thetumorhasgrownintonearbystructures(regardlessofitssize).
Somecancertypesalsohavespecialgroupingsthataredifferentfromothercancertypes.Forinstance,forsome
cancers,classificationsmayhavesubcategories,suchasT3aandT3b,whileothersmaynothaveanN3category.

Stagegrouping
OncethevaluesforT,N,andMhavebeendetermined,theyarecombinedtoassignanoverallstage.Formost
cancers,thestageisaRomannumeralfromItoIV,wherestageIV(4)isthehighestandmeansthecancerismore
advancedthaninthelowerstages.Sometimesstagesaresubdividedaswell,usingletterssuchasAandB.
Stage0iscarcinomainsituformostcancers.Thismeansthecancerisataveryearlystage,isonlyinthearea
whereitfirstdeveloped,andhasnotspread.Notallcancershaveastage0.
StageIcancersarethenextleastadvancedandoftenhaveagoodprognosis(outlook).Theoutlookisusuallynotas
goodforhigherstages.

Otherfactorsthatcanaffectthestage
Forsomecancers,thevaluesforT,N,andMarenttheonlythingsthatdeterminethestage.Someotherfactorsthat
maybetakenintoaccountinclude:
Grade:Formostcancers,thegradeisameasureofhowabnormalthecancercellslookunderthemicroscope.This
iscalleddifferentiation.Gradecanbeimportantbecausecancerswithmoreabnormallookingcellstendtogrowand

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spreadfaster.
Thegradeisusuallyassignedanumber.Inlowgrade(welldifferentiated)cancers,thecancercellslookalotlike
cellsfromnormaltissue.Ingeneral,thesecancerstendtogrowslowly.Inhighgrade(poorlydifferentiated)cancers,
thecancercellslookverydifferentfromnormalcells.Highgradecancersoftentendtogrowquicklyandhavea
worseoutlook,sotheymayneeddifferenttreatmentsthanlowgradecancers.Evenwhenthegradedoesntaffecta
cancersstage,itmaystillaffecttheoutlookand/ortreatment.
Celltype:Somecancerscanbemadeupofdifferenttypesofcells.Becausethetypeofcancercellcanaffect
treatmentandoutlook,itcanbeafactorinstaging.Forexample,cancersoftheesophagusaremainlyeither
squamouscellcancersoradenocarcinomas.Squamouscellesophagealcancersarestageddifferentlyfrom
esophagealadenocarcinomas.
Tumorlocation:Forsomecancers,thetumorslocationaffectsoutlookandistakenintoaccountinstaging.The
stageofcanceroftheesophagus,forexample,dependsonwhetherthecancerisintheupper,middle,orlowerthird
oftheesophagus.
Tumormarkerlevels:Forsomecancers,thebloodlevelsofcertainsubstances(calledtumormarkers)canaffect
thestageofthecancer.Forexample,inprostatecancer,thelevelofprostatespecificantigen(PSA)inthebloodis
takenintoaccountinassigningastage.

Otherstagingsystems
NotallcancersarestagedusingtheTNMsystem.Somecancersgrowandspreadinadifferentway.Forexample,
manycancersinoraroundthebrainarenotstagedusingtheTNMsystem,sincethesecancerstendtospreadto
otherpartsofthebrainandnottolymphnodesorotherpartsofthebody.StagingsystemsotherthantheTNM
systemareoftenusedforHodgkindiseaseandotherlymphomas,too,aswellasforsomechildhoodcancers.
TheInternationalFederationofGynecologistsandObstetricians(FIGO)hasastagingsystemforcancersofthe
femalereproductiveorgans.TheTNMstagescloselymatchtheFIGOstages,whichmakesitfairlyeasytoconvert
stagesbetweenthese2systems.
Other,olderstagingsystems(suchastheDukessystemforcolorectalcancer)maystillbeusedbysomedoctors.If
yourdoctorusesanotherstagingsystem,youmaywanttofindoutifthestagecanbetranslatedintotheTNM
system.Thiswilloftenhelpifyouwanttoreadmoreaboutyourcanceranditstreatment,sincetheTNMsystemis
morewidelyused.

Acancersstagedoesnotchange
Animportantpointsomepeoplehavetroubleunderstandingisthatthestageofacancerisdeterminedonlywhen(or
soonafter)thecancerisdiagnosed.Thisstagedoesnotchangeovertime,evenifthecancershrinks,grows,
spreads,orcomesbackaftertreatment.Thecancerisstillreferredtobythestageitwasgivenwhenitwasfirst
foundanddiagnosed,althoughinformationaboutthecurrentextentofthecancerisadded(andofcourse,the
treatmentisadjustedasneeded).
Forexample,letssayawomanisfirstdiagnosedwithstageIIbreastcancer.Thecancergoesawaywithtreatment,
butthenitcomesbackandhasspreadtothebones.ThecancerisstillcalledastageIIbreastcancer,nowwith
recurrentdiseaseinthebones.
IfthebreastcancerdidnotgoawaywiththeoriginaltreatmentandspreadtothebonesitwouldbecalledastageII
breastcancerwithbonemetastasis.Ineithercase,theoriginalstagedoesnotchangeanditsnotcalledastageIV
breastcancer.StageIVbreastcancerreferstoacancerthathasalreadyspreadtoadistantpartofthebodywhen
itsfirstdiagnosed.
Thisisimportanttounderstandbecausesurvivalstatisticsandinformationontreatmentbystageforspecificcancer
typesrefertothestagewhenthecancerwasfirstdiagnosed.ThesurvivalstatisticsrelatedtostageIIbreastcancer
thathasrecurredinthebonesmaynotbethesameasthesurvivalstatisticsforstageIVbreastcancer.
Atsomepointyoumayhearthetermrestaging.Restagingisatermsometimesusedtodescribedoingteststofind
theextentofthecanceraftertreatment.Thisisrarelydone,butitmaybeusedtomeasurethecancersresponseto
treatmentortoassesscancerthathascomeback(recurred)andwillneedmoretreatment.Oftenthesameteststhat
weredonewhenthecancerwasfirstdiagnosed(suchasphysicalexams,imagingtests,biopsies,andmaybe
surgery)willbedoneagain.Afterthesetestsanewstagemaybeassigned.Itswrittenwithalowercaserbefore

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thenewstagetonotethatitsdifferentfromthestageatdiagnosis.Theoriginallydiagnosedstagealwaysstaysthe
same.Whiletestingtoseetheextentofcanceriscommonduringandaftertreatment,actuallyassigninganewstage
israrelydone,exceptinclinicaltrials.

Findingoutmoreaboutyourtypeofcancer
Fordetailsonstagingorgradingforacertaintypeofcancer,seeourinformationonspecificcancertypes.Youcan
findthisinformationonourwebsite,orcallourtollfreenumberbelow.

Tolearnmore
MoreinformationfromyourAmericanCancerSociety
Thefollowingrelatedinformationmayalsobehelpfultoyou.Thesematerialsmaybeorderedfromourtollfree
number,18002272345,orreadonlineatwww.cancer.org.

Dealingwithcancer
CopingWithCancerinEverydayLife(alsoinSpanish)
AfterDiagnosis:AGuideforPatientsandFamilies(alsoinSpanish)
TalkingWithYourDoctor(alsoinSpanish)

Cancertestsandtreatments
Imaging(Radiology)Tests
TestingBiopsyandCytologySpecimensforCancer
AGuidetoCancerSurgery(alsoinSpanish)
AGuidetoChemotherapy(alsoinSpanish)
UnderstandingRadiationTherapy(alsoinSpanish)

Nationalorganizationsandwebsites*
AlongwiththeAmericanCancerSociety,othersourcesofinformationandsupportinclude:
NationalCancerInstitute
Tollfreenumber:18004CANCER(18004226237)
Website:www.cancer.gov
PartoftheUSNationalInstitutesofHealth,theNCIprovidesfree,accurate,uptodatecancerinformationfor
patients,theirfamilies,andthegeneralpublic
AmericanJointCommitteeonCancer(AJCC)
Phonenumber:13122025313
Website:www.cancerstaging.org
OffersCancerStagingWhatYouNeedtoKnow(www.cancerstaging.org/staging/needtoknow.pdf),abrochurefor
patientsandfamiliesthatexplainstheTNMsystem,listssomecommonlystagedcancers,definestheconceptof
stagegrouping,anddiscussesthepurposeofthecancerregistry
*InclusiononthislistdoesnotimplyendorsementbytheAmericanCancerSociety.
Nomatterwhoyouare,wecanhelp.Contactusanytime,dayornight,forcancerrelatedinformationandsupport.
Callusat18002272345orvisitwww.cancer.org.

References
EdgeSB,ByrdDR,ComptonCC,FritzAG,GreeneFL,TrottiA,eds.AmericanJointCommitteeonCancerStaging
Manual.7thed.NewYork,NY:Springer2010.

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NationalCancerInstitute.CancerStaging.2015.Accessedat
www.cancer.gov/cancertopics/factsheet/detection/stagingonMarch20,2015.
YarbroCH,FroggeMH,GoodmanM,GroenwaldSL,eds.CancerNursingPrinciplesandPractice.5thed.Sudbury,
MA:JonesandBartlettPublishers,Inc.2000.

LastMedicalReview:03/20/2015
LastRevised:03/25/2015
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2015AmericanCancerSociety,Inc.Allrights
reserved.TheAmericanCancerSocietyisaqualified
501(c)(3)taxexemptorganization.Cancer.orgis
providedcourtesyoftheLeoandGloriaRosenfamily.

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